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Contract Compliance Representative (Entry)

Determines provider compliance throughout a region and recommends appropriate actions.: This position is typically responsible for learning investigatory techniques for the detection of inadvertent or intentional fraud. Assists in special investigations and provides support in compliance with requests from enforcement agencies. Researches, handles and assists in resolution of complaints regarding suspected fraud and/or compliance issues. Analyzes documentation and summarizes data gathered from a variety of sources. Interacts with other departments and performs special tasks to include overseeing random examination processes, enforcing membership actions and assessing reports on provider groups or brokers. Conducts ad hoc investigations. This position typically requires at least one year of underwriting experience.

Contract Compliance Representative

Determines provider compliance throughout a region and recommends appropriate actions.: This position is knowledgeable of investigatory techniques for the detection of inadvertent or intentional fraud. Assists in special investigations and provides support in compliance with requests from enforcement agencies. Researches, handles and assists in resolution of complaints regarding suspected fraud and/or compliance issues. Analyzes documentation and summarizes data gathered from a variety of sources. Interacts with other departments and performs special tasks to include overseeing random examination processes, enforcing membership actions and assessing reports on provider groups or brokers. Conducts ad hoc investigations. This position typically requires a college degree in math, economics or a related field and three years of underwriting experience.

Contract Compliance Representative (Mentor)

Determines provider compliance throughout a region and recommends appropriate actions.: This position is knowledgeable of investigatory techniques for the detection of inadvertent or intentional fraud. Assists in special investigations and provides support in compliance with requests from enforcement agencies. Researches, handles and assists in resolution of complaints regarding suspected fraud and/or compliance issues. Analyzes documentation and summarizes data gathered from a variety of sources. Interacts with other departments and performs special tasks to include overseeing random examination processes, enforcing membership actions and assessing reports on provider groups or brokers. Provides first line oversight to less experienced Contract Compliance Representatives. Conducts ad hoc investigations. This position typically requires a college degree in math, economics or a related field and at least five years of underwriting experience.

Provider Relations Representative

Monitors and coordinates governmental or private health care programs to ensure quality health care and facilitate claim processing; and negotiates contracts for health care programs between insurance companies and health care providers: Analyzes reports and documents regarding health care usage of program participants, utilizing computer; compiles list of recurring health care claims processing issues; develops agenda to address issues; and conducts information and training workshops with employees who process and file claims to resolve claim processing errors. Formulates contract draft of agreement between participants of health care program, utilizing information, such as standard agreement procedures, insurance company policies, and governmental requirements, using computer. Presents health care program contracts to participating parties, discusses modifications suggested by parties involved, and obtains signatures of required representatives on new, renewed, or revised contracts. May monitor phone calls received by medical claim processors to evaluate services offered by employees. May investigate and resolve medical care provider claims reimbursement and program procedural problems. May review evaluation forms completed by workshop participants to determine whether workshop presentation covered processing errors. May specialize in contract negotiations or serve as consultant to facilitate claim processing and be designated Provider Services Specialist (government ser.; insurance; medical ser.).

Hospital Insurance Representative

Interprets hospital and medical insurance services and benefits to contracting hospital personnel. Discusses contract provisions and hospital claims forms with medical and hospital personnel. : Instructs hospital clerical staff in resolving problems concerning billing and admitting procedures. Writes reports outlining hospital and contract benefits for incorporation into brochures and pamphlets. May travel from city to city.

Patient Representative

Serves as liaison between the employer, patients, and patients' relatives in resolving patient care problems. Resolves patients' complaints and grievances. : Conveys questions, complaints, problems, and concerns of patients to proper personnel. Describes and interprets patient care procedures, and policies to patients. Prepares reports regarding incidents that may result in legal action if not settled. Trains staff on humanizing patients' care. Establishes rapport with personnel. Takes part in employer's public affairs activities.

Help Desk Representative

Analyzes and troubleshoots computer support problems and applies understanding of computer software and hardware products and services to resolve problems of users. Receives telephone calls and e-mails from users having problems using computer software and hardware or inquiring how to use specific software, programming languages, electronic mail, or operating systems. Ascertains from computer user the nature of problem, determines whether problem is caused by hardware such as modem, printer, cables, or telephone, formulates diagnosis, and assists users through problem solving steps. Organizations usually prefer two years of postsecondary training in field of specialty; however, some companies may accept equivalent education and experience combined.: Talks with co-workers to research problem and find solution. Tests software and hardware to evaluate ease of use and whether product will aid user in performing work. Writes software and hardware evaluation and recommendation for management review. Writes or revises user-training manuals and procedures. Develops training materials, such as exercises and visual displays. Trains users on software and hardware on-site or in classroom, or recommends outside contractors to provide training.

Veterans Contact Representative

Advises and aids veterans or dependents in presenting disability, insurance, or pension claims for benefits under Federal, State, or local laws. : Reviews legislation, regulations, and precedents and studies veteran's medical report and service history to evaluate and determine validity of claim. Obtains claimant's power of attorney. Prepares claim forms and briefs and assembles pertinent evidence. Requests hearing before government board and presents brief. Reviews board decision for grounds for appeal. Advises veteran on insurance, vocational, and other matters, working in cooperation with Veterans Administration and other agencies. Prepares bulletins and correspondence to acquaint field representatives with current activities and legislation. Participates in or initiates civic functions, such as panel discussions and mass communication programs, to inform public of services rendered and rights and benefits of veterans and dependents. May offer technical advice at congressional or other governmental hearings.

Public Relations Representative

Plans and conducts public relations program designed to create and maintain favorable public image for employer or client. Plans and directs development and communication of information designed to keep the public informed of employer's programs, accomplishments, or point of view. Arranges for public relations efforts in order to meet needs, objectives, and policies of individual, special interest group, business concern, nonprofit organization, or governmental agency, serving as in-house staff member or as outside consultant. : Prepares and distributes fact sheets, news releases, photographs, scripts, motion pictures, recordings, or website addresses or articles to media representatives and other people who may be interested in learning about or publicizing employer's activities or message. Purchases advertising space and time as required. Arranges for and conducts public-contact programs designed to meet employer's objectives, utilizing knowledge of changing attitudes and opinions of consumers, clients, employees, or other interest groups. Promotes goodwill through such publicity efforts as speeches, exhibits, films, tours, and question/answer sessions. Represents employer during community projects and at public, social, and business gatherings. May research data, create ideas, write copy, lay out artwork, contact media representatives, or represent employer directly before general public. May develop special projects such as campaign fundraisers or public awareness about political issues. May direct activities of subordinates. May confer with production and support personnel to coordinate production of television advertisements and on-air promotions. May prepare press releases and fact sheets and compose letters. May disseminate facts and information about organization's activities or governmental agency's programs to the general public.

Business Development Representative

Supports business development and marketing of the organization's products by maintaining records and promoting products to brokers, third party administrators, self-funded employers, and Human Resources Departments. A bachelor's degree in marketing is typically required for this position with two years of business development or marketing experience.: Maintains the Business Development databases that include proposals, budgets, project costs and analyses, letters, mailings, and contracts. Produces monthly management reports and supports client service and marketing activities. Supports business development activities by assisting with the contracting and marketing of such activities to existing and potential clients. Assists management in the development of business plans, marketing strategies, sales calls, and general marketing of the business development activities of the organization. Conducts ongoing research of new product lines, making recommendations to the appropriate individuals. Facilitates efforts to develop, implement, and refine standard procedures for researching, collecting, and tracking information about clients including contact data, pipelines, and previous outsourcing experiences.

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